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ONLINE CASE STUDIES: HESI EXIT

EXAM SCORES AND


NCLEX-RN OUTCOMES
ANNE YOUNG, EDD, RN⁎, GLORIA ROSE, PHD, RN, FNP-BC†,
AND PAMELA WILLSON, PHD, RN, FNP-BC, CNE‡

Using data obtained for the 7th HESI Exit Exam (E 2) validity study, the value of Elsevier's online
case studies in assisting students to prepare for the E 2 and the National Council Licensure
Examination for Registered Nurses (NCLEX-RN) was investigated. Of the 137 randomly
selected schools of nursing, 72 (52.55%) participated in the study. The student sample consisted
of 4,383 students from associate degree, baccalaureate, and diploma schools of nursing. Findings
indicated that the mean E 2 score and the NCLEX-RN pass rate were significantly higher for
students attending schools that used the case studies than they were for students attending
schools that did not use the case studies. Descriptive data indicated that the case studies were
most often used for remediation and examination preparation. (Index words: Case study; HESI
Exit Exam; NCLEX-RN outcomes) J Prof Nurs 29:S17–S21, 2013. © 2013 Elsevier Inc. All rights
reserved.

S EVEN PREVIOUSLY PUBLISHED studies indicate


that Elsevier's HESI Exit Exam (E 2) is a highly
accurate predictor of success on the National Council
efforts that address their particular learning needs.
However, methods used to prepare students for the
licensure examination and to remediate academic
Licensure Examination for Registered Nurses (NCLEX- weaknesses identified by the E 2 so that candidates
RN) (Adamson & Britt, 2009; Lauchner, Newman, & can achieve first-time success on the NCLEX-RN have
Britt, 1999; Lewis, 2005; Newman, Britt, & Lauchner, not been adequately researched. A plethora of NCLEX-
2000; Nibert & Young, 2001; Nibert, Young, & RN review books designed to assist students in
Adamson, 2002; Young & Willson, 2012). Consequently, reviewing content presented throughout the nursing
many schools of nursing use the E 2 as a predictor of curriculum are available for purchase. Yet, knowledge
students' preparedness for the licensure examination and of content alone is not sufficient to achieve acceptable
as a guide for students' remediation needs. Numerous E 2 scores, pass the NCLEX-RN, and perform compe-
subject matter scores reported by the E 2 provide students tently in the clinical area. Students and new graduates
with the information they need to focus remediation must also be able to apply nursing content and
concepts to specific clinical situations and use critical
thinking skills to solve clinical problems.
∗Professor, Texas Woman's University, College of Nursing, Houston,
TX.
†Clinical Assistant Professor, Prairie View A&M University, College of
Review of the Literature
Nursing, Houston, TX. Case studies have long been used as a teaching method in
‡Associate Director of Education, Michael E. DeBakey VA Medical business, law, and medicine because they provide an
Center, Houston, TX.
effective means of applying content and assisting
Disclosure statement: Dr. Young and Dr. Rose have participated in
research activities and received presentation honoraria from HESI
students to develop problem-solving skills (Delpier,
Review & Testing within the past 3 years. Dr. Young serves as 2006). The use of case studies for teaching is generally
Chairperson of the Research Advisory Board for HESI Review & Testing. considered superior to lectures in promoting learners'
Dr. Willson was employed by HESI Review & Testing at the time this critical thinking skills, and students report a preference
research was conducted. for interactive teaching strategies over didactic methods
Address correspondence to Dr. Young: Texas Woman's University,
College of Nursing, 6700 Fannin, Houston, TX 77030. E-mail: eyoung@ (Kim et al., 2006). Interestingly, despite students' pre-
mail.twu.edu ference for interactive teaching strategies and faculties'
8755-7223/12/$ - see front matter belief that case studies are superior to didactic teaching
Journal of Professional Nursing, Vol 29, No. 2S (March/April), 2013: pp S17–S21 S17
© 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.profnurs.2012.06.010
S18 YOUNG ET AL

methods, little or no difference has been found in terms This study was designed to verify Mihal's findings
of students' learning outcomes when comparing the use regarding the E 2 scores of students with and without
of case studies and didactic teaching strategies (Beers, access to case studies. However, since the Mihal study
2005; Costa, van Rensburg, & Rushton, 2007; Lauver, was completed, case studies' licenses have become a
West, Campbell, Herrold, & Wood, 2009). However, component of several testing packages, and current
studies that compared teaching methods could have access to them does not necessarily mean that they are
been affected by the methods used to evaluate learning being implemented as a teaching strategy. This study
outcomes, which were usually traditional tests that determined users and nonusers of case studies based on
measured knowledge of content, rather than exams deans' and directors' reported use of the case studies,
designed to measure critical thinking. The E 2 and the rather than merely having a license to use the case
NCLEX-RN, both of which are designed to measure studies. For the purpose of this study, two terms were
critical thinking within the discipline of nursing, might defined: (a) case studies—Elsevier's online case studies
be a better measure of the effectiveness of case studies that were licensed for use to schools of nursing; and (b)
in terms of students' learning outcomes. The use of case users of case studies—students who attended schools of
studies as a teaching strategy in nursing has been nursing where deans and directors identified their school
reported to promote critical thinking, develop students' as a user of the case studies. Specifically, the purpose of
clinical reasoning skills, and enhance students' prob- this study was to (a) determine if E 2 scores of students
lem-solving abilities (Dowd & Davidhizar, 1999). who used the case studies differed from E 2 scores of
With the advent of instructional technology, innova- students who did not use the case studies, (b) determine
tive teaching strategies have been developed to assist if NCLEX-RN outcomes of candidates who used the case
students in achieving curricular and licensure success studies differed from NCLEX-RN outcomes of candidates
using self-paced learning opportunities. The online case who did not use the case studies, and (c) describe the
studies provided by Elsevier are self-paced learning methods used to implement the case studies.
tools designed to assist students with the application of
nursing knowledge and concepts in clinical situations, Methodology
and as such, they are believed by many faculties to be A nonexperimental, descriptive design was used to
an effective teaching strategy in helping students compare E 2 scores of students who used Elsevier's online
prepare for the E 2 and the NCLEX-RN. Schools of case studies with E 2 scores of students who did not use
nursing may purchase a license to use the Elsevier case the case studies. As part of the seventh E 2 validity study
studies, which are marketed as patient situations (S7), data were obtained from deans and directors at 72
accompanied by critical thinking questions that help randomly selected schools of nursing that administered
students learn to manage complex patient conditions the E 2 between September 1, 2006, and August 31, 2007
and make sound clinical judgments. However, limited (Young & Willson, 2012). These participating deans and
research has been conducted to study the effectiveness directors were asked to complete the S7 Participant
of these case studies as a teaching tool and/or a School Survey, an electronic instrument that requested
remediation resource. information regarding NCLEX-RN outcomes and use of
Mihal (2006) is the only study completed to date that the case studies. Additionally, data obtained from the
has investigated the effectiveness of Elsevier's online case three questions on the S7 Participant School Survey
studies. Using data obtained from Elsevier's database, regarding case study implementation methods were used
Mihal divided schools into two groups: those that were for descriptive purposes.
licensed to use the case studies and those that were not
licensed to use the case studies. Then, the mean E 2 scores Instrumentation
for these two groups were compared. The mean E 2 score Two instruments were used to obtain data for this study:
for the 1,544 students who attended the 34 schools of the E 2 and the S7 Participant School Survey. The E 2
nursing that were licensed to use the case studies was consists of 160 test items, 10 of which are pilot items that
896.71, and the mean E 2 score for the 21,241 students are not scored. It is a comprehensive exam that is
who attended the 344 schools of nursing that were not administered to students near the completion of the
licensed to use the case studies was 859.88. A t test for nursing curriculum to measure their preparedness for the
two independent samples was used to compare the mean NCLEX-RN. The test items are written using a critical
E 2 score of students who attended schools that were thinking model described by Morrison, Nibert, and Flick
licensed to use the case studies with the mean E 2 score of (2006) and require clinical nursing judgment to deter-
students who attended schools that were not licensed to mine the correct answer. Morrison, Adamson, Nibert,
use the case studies. Findings indicated that the mean E 2 and Hsia (2004) described the reliability and validity of
score for those who attended schools that were licensed the E 2 . A reliability estimate or Kuder–Richardson
to use the case studies was significantly higher (t = 9.979, Formula 20 (KR20) is calculated for every E 2 prior to
P ≤ .000) than the mean E 2 score for students who its administration and is based on item analysis data
attended schools that were not licensed to use case obtained from all previous uses of the test items
studies, thereby suggesting that Elsevier's online case contained in the exam. The mean estimated KR20 for
studies positively affected students' E 2 scores. the E 2s administered during the study period was 0.926
ONLINE CASE STUDIES S19

Table 1. Description of Schools and Students by Program Type Table 3. NCLEX-RN Outcomes of Students Who Attended
and HESI Case Study Use Schools That Used HESI Case Studies and Students Who
Attended Schools That Did Not Use HESI Case Studies
Number of Number of
schools students Number Number
Program type (%) passed (%) failed
ADN 45 2,557 HESI case studies Number NCLEX-RN NCLEX-RN
BSN 22 1,617 Students attending 1,437 1,332 (92.69) 105 (7.31)
Diploma 5 209 schools that used
Total 72 4,383 the case studies
Students attending 2,484 2,223 (89.49) 261 (10.51)
HESI case study use schools that did
Used the case studies 24 1,597 not use the
Did not use the case studies 48 2,786 case studies
Total 72 4,383 Total 3,921 ⁎
Note. The NCLEX-RN pass rate was significantly higher for students who
(Elsevier's HESI database, August 2011). Criterion- attended schools that used the HESI case studies than for students who
attended schools that did not use the HESI case studies, χ2(1, N = 3,921)
related validity of the E 2 has been established by the = 10.64, P ≤ .001.
seven validity studies that have been conducted over the ⁎ NCLEX-RN outcomes were not available for 462 of the total sample
past 12 years, indicating that the E 2 is between 96.36% of 4,383.
and 99.16% accurate in predicting NCLEX-RN success
(Adamson & Britt, 2009; Lauchner et al., 1999; Lewis, participating students, 1,597 (36.44%) attended schools
2005; Newman et al., 2000; Nibert & Young, 2001; that used the case studies, and 2,786 (63.56%) attended
Nibert et al., 2002; Young & Willson, 2012). schools that did not use the case studies (see Table 1).
The S7 Participant School Survey consisted of multi- The mean E 2 score of the 1,597 students who used the
ple-choice items with open comment fields. Data case studies was 868.79, and the mean E 2 score of the
obtained from this instrument were used to determine 2,786 students who did not use the case studies was
students' outcomes on their first attempt at taking the 849.62. A t test analysis indicated that the students who
NCLEX-RN and to glean descriptive data regarding used the case studies had significantly higher E 2 scores
strategies used to implement the case studies. All than the students who did not use the case studies,
identifying information was removed prior to providing t(3,229) = 4.58, P ≤ .000, (see Table 2).
data to the researchers regarding NCLEX-RN pass rates Of the 4,383 participating students, NCLEX-RN out-
and case study implementation methods. comes were unavailable for 462 students because they did
not graduate, their NCLEX-RN outcomes were unavail-
Findings able to their deans or directors, or the deans or directors
Nursing schools were randomly selected to participate in declined to provide the data. Therefore, the total student
S7, and of the 137 schools selected for participation, 72 sample used for analysis regarding NCLEX-RN outcomes
(52.55%) responded to the Participant School Survey. Of consisted of 3,921 students: 1,437 (36.65%) who used the
the 72 responding nursing schools, 45 (62.50%) were case studies and 2,484 (63.35%) who did not use the case
associate degree (ADN) programs, 22 (30.56%) were studies. Of the 1,437 students who used the case studies,
baccalaureate (BSN) programs, and 5 (6.94%) were 1,332 (92.69%) passed the NCLEX-RN on their first
diploma programs. The total student sample consisted attempt, and 105 (7.31%) failed. Of the 2,484 students
of 4,383: 2,557 (58.34%) ADN students; 1,617 (36.89%) who did not use the case studies, 2,223 (89.49%) passed
BSN students; and 209 (4.77%) diploma students. Of the the NCLEX-RN on their first attempt, and 261 (10.51%)
72 participating schools, 24 (33.33%) schools reported failed. Because NCLEX-RN outcomes are reported as
that they used the Elsevier online case studies within pass/fail, which are nominal-level data, a chi-square was
their school of nursing, and 48 (66.67%) reported that used to analyze the data. Findings indicated that
they did not use the case studies. Of the total 4,383 significantly more students who used the case studies

Table 2. Comparison of Mean E 2 Scores for Students Who Attended Schools That Used HESI Case Studies and Students Who
Attended Schools That Did Not Use HESI Case Studies
Confidence
2 interval 95%
Mean E
HESI case study use n score SD t P Lower Upper
Students attending schools that used the case studies 1,597 868.79 135.07 4.58 ≤ .000 10.95 27.37
Students attending schools that did not use the case studies 2,786 849.62 130.39
Total students 4,383
Note. Mean E2 scores were significantly higher (P ≤ .000) for students who attended schools that used HESI case studies than for students who attended
schools that did not use HESI case studies.
S20 YOUNG ET AL

Table 4. HESI Case Study Implementation Methods Described scores could have been influenced by intervening vari-
by Schools of Nursing That Used the HESI Case Studies ables. For example, it is possible that the faculty at
Number of Percent of schools that used the case studies worked more closely
Method schools schools with students in helping them remediate than did the
faculty at schools that did not use the case studies, which
Remediation 18 75.00
might explain why they purchased the case study license
Exam preparation 15 62.50
Course grade 8 33.33 in the first place—to help students remediate. Such
Clinical preparation 6 25.00 faculty assistance might explain why students who used
Postclinical conference 5 20.83 the case studies had higher E 2 scores and a higher
Total 24 ⁎ NCLEX-RN pass rate than students who did not use the
⁎ More than one method may have been implemented by individual case studies. Additionally, the quality of the student
schools. population at each school could have differed, thereby
influencing the findings of this study. Future studies
regarding the usefulness of case studies should investi-
passed the NCLEX-RN on their first attempt than gate the E 2 scores and NCLEX-RN outcomes of
students who did not use the case studies, χ 2(1, N = individual students, and researchers should also consider
3,921) = 10.64, P ≤ .001, (see Table 3). stratifying the sample by the number of the case studies
Deans and directors of the 24 schools that reported each student completed, rather than simply looking at
using the case studies answered three questions on the S7 those who attended schools that reported using the case
Participant School Survey regarding methods used to studies. As it was in this study, all identifying student
implement the case studies within their school of information should be expunged prior to providing the
nursing. Based on data obtained from responses to data to the researchers so that the participants' confiden-
these questions, the primary uses for the case studies tiality is protected.
were remediation and exam preparation. Of the 24 This was a preliminary study that investigated methods
schools that used the case studies, 18 (75.00%) deans or used to implement case studies and, as such, provided
directors described using the case studies for remedia- descriptive data only. Future studies should obtain a
tion, and 15 (62.50%) described using the case studies for larger sample size of schools that use the case studies and
exam preparation. The case studies were used as part of compare case study implementation methods in terms of
the course grade by 8 (33.33%) of the schools, for clinical E 2 scores and NCLEX-RN outcomes, thereby scientifi-
preparation by 6 (25.00%) of the schools, and for cally investigating the value of various methods used to
postclinical conferences by 5 (20.83%) of the schools implement case studies within schools of nursing.
(see Table 4).
Conclusions
Summary, Discussion, and
Recommendations Seven previously published studies indicate that the E 2 is
highly accurate in predicting NCLEX-RN success, and
This study was based on data obtained for S7, which the findings of this study provide nursing students and
investigated the predictive accuracy of the E 2 by nursing faculty with direction in terms of preparing for
soliciting information from the deans or directors of the the E 2 and ultimately for the NCLEX-RN. Deans and
participating schools regarding students' NCLEX-RN directors reported that Elsevier's online case studies were
outcomes. Data regarding schools' use of the Elsevier most often used for remediation and exam preparation. It
online case studies were reported by the deans or seems that the case studies were helpful with remedia-
directors that responded to the S7 Participant School tion and exam preparation because both the mean E 2
Survey. Mean E 2 scores and NCLEX-RN pass rates of score and the NCLEX-RN pass rate were significantly
students who used the case studies and those who did not higher for students who used the case studies than for
use the case studies were compared. Both E 2 scores and students who did not use the case studies. It would
NCLEX-RN pass rates were significantly higher for therefore seem judicious for deans and directors to
students who used the case studies. It is likely that E 2 consider using the Elsevier online case studies to assist
scores and students' first-time NCLEX-RN success rate students in preparing for the E 2 and ultimately for the
were higher for those who used the case studies because licensing exam.
the case studies focus on application of content and
require the use of critical thinking skills to answer the References
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ONLINE CASE STUDIES S21

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